Digital learning designs in occupational therapy education: a scoping review

Background Digital learning is a rapidly advancing method for teaching and learning in professional health education. Although various digital learning designs have been tried in OT education, studies on digital learning designs are still limited. Methods We conducted a scoping study that aimed to identify the digital learning designs used in occupational therapy (OT) education and review the effectiveness, learner perceptions, clinical skills integrated, and technology-based learning strategies used to facilitate learning. Four databases were searched using subheadings and terms relating to digital learning, occupational therapy, and education. The included studies were mapped according to the types of digital learning design, subjects, key clinical skills, and outcomes. Results Twenty-two studies were included in this review, most of which were qualitative, observational, or mixed studies of the two designs. The digital learning designs identified in OT education were flipped, blended, hybrid, and distance learning, including e-learning and massive open online courses (MOOC). Among the components of clinical skills, professional reasoning and procedural knowledge were the most integrated into digital learning, and covered various OT subjects. Digital learning designs were reported to be equivalent to or more effective than the traditional face-to-face (F2F) class in learning outcomes of knowledge and skill acquisition, enhancing learning participation, reflection, and collaboration between learners. Various technologies have been used to promote synchronous or asynchronous active learning, providing learning strategies such as thinking, reflection, discussion, peer learning-group activity, and gamifying online learning. Conclusions In OT digital learning, appropriate learning subjects, the arrangement of clinical skill components that can be well integrated into digital learning, and the selection of appropriate technologies for effective learning are important. The results should be confirmed within an experimental study design.

individual learners' knowledge and skills and effective teaching methods through a variety of modalities using information and communication technologies such as computer-assisted, mobile, and digital simulation-based learning [2,3]. Digital learning consists of digital teaching materials (e-textbooks, digital data, and content provided in digital format), digital tools (computers and smart devices), and digital delivery (Internet), which are provided in an integrated manner [4].
Digital learning design can be largely divided into blended and distance learning, such as a full e-learning course. Blended learning is a learning design that combines face-to-face (F2F) and online teaching with synchronous learning (provided in real-time, F2F or online) and asynchronous learning (provided in flexible time and online). Distance learning is a completely online learning design. In distance learning, learning and teaching take place using computers via a web-based system or a specific course management system that facilitates learnerteacher communication and is delivered completely asynchronously [5].
The professional occupational therapy (OT) program fosters culturally sensitive and evidence-based clinical competency by allowing learners to participate actively in the collaborative process between students, clients, and educators. Therefore, learners should be able to integrate academic knowledge, professional reasoning, and self-reflection through active learning through various experiences both inside and outside the classroom [6,7]. Digital learning design in OT and physical therapy (PT) education has not been based on theoretical learning and has been frequently adjusted from a short perspective [1], although Bajpai et al. [8]. suggested guidelines for the theory of digital learning in professional health education. Nevertheless, various digital technologies (e.g., quizzes, videos, and social media) are currently being applied in the context of learning and teaching, such as learning feedback, assessment, clinical skills and techniques, and fieldwork supervision in OT and PT education [9].
Previous reviews have suggested that the effectiveness of blended learning [10], flipped learning [11], and e-learning [12] in healthcare education is equivalent or superior to traditional class teaching methods. Ødegaard et al. [13] also reported that blended learning and distance learning in PT education are equally or more effective than traditional teaching methods. In terms of planning digital learning in OT education, it is necessary to determine how to design digital learning to achieve learning outcomes and what clinical skills and subjects can be integrated into digital learning. Studies have applied various digital learning designs in OT education. However, a recent review of digital learning design has not been conducted, so it is necessary to explore the digital learning design studies conducted so far in OT education and to map and summarize the evidence for the applied digital learning design. This scoping review aims to identify (i) the digital learning design used in OT education, (ii) key clinical skills and subjects integrated into the design, (iii) technology-based learning strategies used to facilitate learning, and (iv) to explore digital learning outcomes and students' perceptions.

Methods
We adopt a scoping review methodology based on the process outlined by Arksey and O'Malley [14,15]. In steps 2 and 3, the preferred reporting items for systematic reviews and meta-analyses (PRISMA) [16] were used to identify and select relevant studies.

Stage 1: identifying the research question
To explore the literature on digital learning in OT education, we present the following research question: What digital learning design was applied in OT education, and what were the outcomes and students' perceptions?

Stage 3: study selection
We included quantitative, qualitative, or mixed method study designs, full-text articles, English language, and material that met the following criteria for facilitating learning: those focused on digital learning design (e.g., blended learning, distance learning) or the use of technology-based learning strategies (e.g., peer learning group work, gamify online learning); a study population of OT students in bachelor's/undergraduate, MOT (Master of Occupational Therapy), OTD (Occupational Therapy Doctorate), and occupational therapists participating in OT continuing education programs and reported on the outcomes of exams on knowledge and skills, usefulness, and students' perceptions (e.g., satisfaction with learning, self-efficacy). In addition, the publication period was limited to January 2000 -February 2022. In the late 1990s, learning opportunities and designs using technologies such as the Internet, computers, e-mail, and interactive video and audio communication began to emerge as new educational models. Since the application of digital learning using technologies was limited before 2000 in OT education, the search was limited to studies published after 2000. The exclusion criteria were protocol studies, expert opinion studies, theses, dissertations, conference abstracts, education not for OT students or occupational therapists, and studies in which digital learning technologies were not used as part of a learning strategy. The authors agreed to include only studies that explicitly used digital learning designs in this scoping review through an iterative review process at the time of full-text review.

Stages 4 and 5. Charting the data and collating, summarizing, and reporting the results
Two researchers independently extracted data from the included studies using an extraction form. Another researcher confirmed that the data synthesis strategy was followed and included data on the author, publication date, study design, participants, subject, key clinical skill and context, interventions (digital learning designs), outcomes (e.g., academic performance, participation, satisfaction), and student experience.
Clinical skills included physical examination skills, practical procedures, communication skills, and management. It also comprises basic scientific knowledge, procedural knowledge, and professional reasoning [17]. In this review, we identified the key clinical skills integrated into each digital learning design.
Several terms have been used for digital learning. In this review, digital learning types were classified according to the most frequently used terms in the literature pertaining to the technical and pedagogical aspects of educational technology [13] and previous reviews on digital learning designs in physiotherapy education [18].

Blended learning
Blended learning refers to a mixed system of education involving the mobilization of learning contexts such as face-to-face and online learning. It also focuses on the integration of different teaching methods, the interaction of different technological tools, and the adoption of virtual spaces in the educational process [18]. Mixed learning by adding online learning materials and activities to offline classes is not intended to replace traditional F2F classes [19,20]. Examples include a scene in which online activities, such as communication and sharing activities using tablets and smartphones, or realistic content, such as augmented reality (AR), are integrated into offline classes.

Hybrid learning
Some students attend classes in person, whereas others attend classes virtually at the location of their choice. Educators use tools such as video-conferencing hardware and software to teach remote and F2F students simultaneously. Some F2F classes are replaced by online components, and online interactions can be either synchronous (e.g., online interactions in real-time via Zoom) or asynchronous (e.g., online interactions at different times via online discussions or VoiceThread) [19,21].

Flipped learning
The method of interaction between students and the learning content in traditional classes is reversed. A method of learning that typically includes both F2F and online components in which basic knowledge is learned prior to class, such as reading, podcasts, or videos, and then expanded through activities conducted in class with the support of an instructor [19,22].

E-learning
This is a form of distance learning that allows learners access from different geographic locations. Various elements of the education strategy (e.g., animations, graphics, videos, forums, chats, quizzes) are delivered in an electronically structured course. Students and instructors can use e-learning systems both asynchronously and synchronously. Synchronous e-learning can be conducted in a real-time interactive manner, and even when simultaneous online access is not possible, forums, e-mails, and mailing lists can support student-instructor relationships, enabling flexible learning [23].

M-learning
A form of e-learning that has emerged with the use of mobile devices in education, typically used outside the classroom. People can use their mobile devices to access educational resources, connect with others, or create content inside and outside the classroom [23].

Massive open online courses (MOOC)
"MOOC integrates the connectivity of social networking, the facilitation of an acknowledged expert in a field of study, and a collection of freely accessible online resources" [24]. The course includes videos, exercises, presentations, and assessments.
The thematic information identified and extracted from each study was tabulated based on the type of digital learning design, integrated subject, context, comparison group, detailed learning activities, and key findings. Textual descriptions were created after analysis according to the digital design type. The themes and summaries of the studies were organized by research question (Table 1), and findings related to each question were discussed.

General features of the selected studies
We included 22 studies (Fig. 2) with 2143 participants (sample size range between min = 10; max = 1009). The participants were occupational therapists (n = 1), OTD program students (n = 5), MOT program students (n = 7), integrated BS/MS OT program students (n = 1), OT undergraduate students (n = 8), and the occupational therapy assistant (OTA) program (n = 1). In addition to students majoring in OT, students majoring in physical therapy, speech and language pathology, medicine, nursing, dentistry, dental hygiene, and nutrition were also included in the studies. The study design was used to investigate the effects of digital learning on academic performance and participants' perceptions of digital learning experiences. Mixed methods (n = 9) were the most common, followed by qualitative methods (gathered interview and focus group data) (n = 5), quasiexperimental (n = 3), randomized controlled trial (n = 1), descriptive (n = 3), and analytical (n = 1) methods. A summary of the characteristics of the selected studies is shown in Table 1.
The variables used to measure the outcomes of digital learning were academic performance (e.g., course grades, exam scores, course objective achievement) (n = 11), professional reasoning skills (n = 4), class participation (n = 3), satisfaction with learning (n = 2), preference for instructional methods (n = 2), usefulness (n = 2), cognitive and emotional empathy (n = 1), a sense of belonging, acquired skills, practice setting, and leadership (n = 1), metacognition of learning (n = 1), and self-efficacy with computer technologies (n = 1). In addition, students reported the benefits and challenges they perceived in digital learning, such as activation of interaction, satisfaction, improved self-confidence, increased participation, effectiveness and efficiency, promotion of active learning, and improvement of professional reasoning and busywork (n = 13) ( Table 2).

Blended learning
Blended learning was used in seven studies. Barillas [25] used 3D anatomy software with F2F sessions on human anatomy subjects; the blended group showed higher learning outcomes than the F2F group, and students reported that the software was helpful in understanding the course concept. Grant [28] used game software for the use and fitting of adaptive equipment during classes. The participants showed high participation in gamebased learning and increased confidence in the practice of adaptive equipment. Other studies using blended learning have integrated synchronous or asynchronous online sessions with F2F sessions and addressed various course subjects. Howard [26] addressed OT theory: the F2F group showed significantly higher academic performance than the blended group, and the blended group reported that online sessions required a lot of busy work. However, in the study by Simons et al. [27], students reported that blended learning in OT theory was effective, efficient, and satisfactory, as expected before the course. Murphy et al. [39] addressed case-based professional reasoning; the blended group showed a significant improvement in overall reasoning in the pre-test and post-test, unlike the F2F group. In the study by Barnard-Ashton et al. [38], the subject was problem-based learning scenario lecturers, and students reported that blended learning facilitated active learning (improved communication and efficient use of time and learning resources). Carbonaro et al. [31] addressed interprofessional skills for undergraduate health science students composed of several majors. The blended and F2F groups showed similar improvements in learning outcomes, and the blended group students reported that the class had a positive impact on collaboration as healthcare members (Tables 1, 2).

Hybrid learning
Hybrid learning was adopted in two studies. Feldhacker et al. [42] provided all OTD courses for one semester in two delivery types: hybrids and F2F. After completion of the course, both the hybrid and F2F groups showed similar improvements in learning outcomes, and students reported that tasks linked to real-life experiences facilitated active learning, regardless of course delivery type.
In the study by Banning [43], the two groups also showed similar improvements in learning outcomes, and there was no significant difference in the perception of certification exams or job preparation (Tables 1, 2).

Flipped classroom
A flipped classroom design was used in two studies. Henderson et al. [33] compared the flipped course group with the subject of adult practice and the group involved in the flipped course design; both groups showed equal effects on learning outcomes and professional reasoning skills. Students participating in the study by Lewis-Kipkulei et al. [44] mentioned that flipped learning has a positive impact on peer interaction and collaboration, and the benefits of having more personalized time for learning (Tables 1, 2).

E-learning
Ten studies used e-learning courses. In three studies with a F2F comparison group, there were no significant differences between the e-learning and F2F groups in course satisfaction or academic performance. The course subjects of these studies were psychosocial dysfunction [29], the communication partner training (CPT) program for adults with aphasia [30], and the DLW framework [37], which were delivered by e-learning and F2F. Six studies included course subjects without the F2F comparison group. Gee et al. [40] addressed case-based professional reasoning for sensory processing, and students trained in the professional reasoning process showed high achievement in professional reasoning strategies and reported  -Students' perception on online hybrid section: the course required more busywork.
-Priori themes: value of theory and growth in theory application -Emergent themes: use of theory for professional reasoning, client-centered practice, theory integration in practice, and theory in the OT process Simons et al. 2002 [27] Experimental group: F2F sessions + online sessions (lectures, presentations, web sites links, and discussion, assignments) via LMS; Web-Course-In-a-Box Duration: 1 semester Online learning experience: students reported that it was efficient, effective, and satisfactory, as previously expected.
ASCT: increased significantly during the semester only in OT course (word processing: p = 0.000, e-mail: p = 0.013, use of the Web: p = 0.025)

Qualitative analysis
-Efficiency, effectiveness, and satisfaction of online learning are a product of the interaction between the individual student factors, remote learning environment factors, and course design and instructor factors.
Grant 2019 [28] Experimental group: Game-based technology during a class to encourage the engagement with practical aspects of equipment use and fitting, Individual and group game missions Duration: 3-hour

Students' perception of game-based learning
-Extremely high student engagement and increased confidence in practicing using adaptive equipment -Students perceived that the game-based technology is useful tool to get knowledge about adaptive equipment.

Qualitative analysis
-Students mentioned that game-based learning allowed them to experience autonomy and competition.
Lin et al. 2021 [29] Smart class group: online teaching information platform ; pre-class (requirements, studying materials), in-class (theoretical class: discussion, questions, and answers/ practical class: practice and discussion) after-class (assignments, group discussion, extracurricular studying resources) Traditional class group: F2F teaching (theoretical class + practical class)

Duration: 1 semester
Course scores: no significant difference in final score between two groups (p = 0.874); higher assignment score and practical exam score in the smart class group than those in the traditional class group (p = 0.017, p = 0.040, respectively) Pre-class preview, in-class learning, after-class review: no significant difference between two groups (p > 0.05, all) Course satisfaction: no significant difference between two groups (p > 0.05) Students' questionnaire survey and teachers' interview: preference for combining the two learning methods (smart class module for the theory class + traditional class for the practical class)

Qualitative analysis
-Students perceived that their understanding and knowledge of other disciplines' roles on the team increased.
-Students felt more comfortable with the idea of collaborating with other disciplines.
-Problem solving and decision-making were improved through factual knowledge about content and the process of applying it.
-Students recognized critically analyzing and evaluating viewpoints as the most positive aspect of learning through this course.

Use of multimedia resources: highly rated in course feedback
Kim et al. 2022 [37]

Qualitative analysis
-Lecturers and students noted improved communication, curriculum transparency and efficient use of time and paper resources, which in turn accommodates the student's need for instant gratification.
-Students felt reassured that they had the correct information and any-time access to all communication resulting in the use of blended learning becoming part of their study habits.
-Lecturers perceived success in seeing students actively engaged with blended learning activities and evidence that blended learning was contributing to improved pass rates.

Murphy et al. 2018 [39]
Experimental group: online videos of cases in real clinical setting and student discussion on professional reasoning in class, out-of-class assignments (small group and individual) Control group: written case studies using a textbook and student discussion on professional reasoning in class, text-based case study assignments (small group

Qualitative analysis
-Flipped classroom has a positive impact on peer interaction and collaboration.
-Flipped classroom provides students more individualized time. -The learning model had a positive impact on encouraging higher student engagement.
-Learning through discussion was much more valuable than traditional lecture courses.
-The course was more student-focused, supporting independent learning.
Benaroya et al. 2021 [45] Experimental group: OTA online education using active learning strategies -Synchronous virtual classroom platform: flipped classroom, think-pair-share and jigsaw technique using breakout rooms, polling and student response systems, muddiest point via chat box, lab kits, -LMS: 1-minute paper using discussion forums, student-generated video Duration: 2 semesters Helpfulness of each strategy: breakout room and chat box feature of the synchronous virtual classroom, lab kits were perceived as most helpful, whereas student-generated videos and one-minute papers were perceived as least helpful Provident et al. 2015 [46] Experimental group: online OTD program via LMS; Moodle -Assignments related to each student's professional interest/practice -Ongoing discussion forums by instructors -Reflective writing activities and peer review processes -Implementation of the capstone project -2 campus visits for leadership course, presentation of capstone projects Duration: 4 semesters Qualitative analysis -Students had multiple opportunities for critical reflection and discourse throughout the program; students experienced professional uneasiness or a dilemma.
-Students reflected that the program's cohort structure allows for the sharing and interaction of experiences with instructors and other students.
-Capstone projects provided active learning in each student's unique worksite making the personal transformation more evident to the student.
-Students reported increased confidence in their new roles and increased awareness of positive change after completing the OTD program.
3D three-dimensional, F2F face to face, OT occupational therapy, ASCT adapted self-efficacy with computer technologies, AASK aphasia attitudes, strategies and knowledge, CPT communication partner training, SCA supported conversation for adults with aphasia, MOOC massive open online courses, APLOS adult practice learning objectives survey, SACRR self-assessment of clinical reflection and reasoning, PMQ Plattner metacognition questionnaire, WebCT web courset tools, DLW do-live-well, VLE virtual learning environment, HSRT health science reasoning test, A SECRET attention, sensation, emotional regulation, culture/context/ condition, relationships, environment, and task, OPPM occupational performance process model, SR scientific reasoning, WGCTA Watson-Glaser critical thinking appraisal, OTA Occupational Therapy Assistant, OTD Occupational Therapy Doctorate positive aspects in teaching methods, evaluation, and content. In the e-learning course, five studies used OT courses through the learning management system (LMS). Benaroya et al. [45] and Provident et al. [46] provided online courses using active learning strategies (e.g., discussion forums, reflective writing activities, and peer review) through an LMS. Students reported that the use of online platforms with integrated active learning strategies increased interaction and sharing between learners and helped them learn. In particular, it was reported that Provident et al. 's [46] capstone project led to personal transformation at each unique worksite. Thomas et al. [35] conducted online fieldwork training during placement via the LMS. Students showed a high participation rate (95%), commented on the advantages of active learning integrated into e-learning, such as peer learning, autonomy, and self-directed learning, and promoted higher-order thinking. Myers et al. [36] provided inter-professional skill training consisting of case study assignments, blogging, multimedia content, and small group activities via the LMS to students majoring in OT, PT, and speech-language pathology (SLP). Students perceived that this e-learning course improved their understanding and knowledge of different disciplines' roles and was useful for developing critical analysis and evaluation skills from the viewpoint of problem-solving. Mitchell et al. [41] also used an active learning strategy through LMS and reported that online tasks had a positive effect on reinforcing awareness and the use of professional reasoning skills. One study compared three online delivery methods [34]. The study was conducted by rotating three online methods: two-way interactive video and audio, chat room groups, and independent case assignments. There was no significant difference in students' task performance between the three methods, and students reported that interaction between learners was an important factor for effective distance learning (Tables 1, 2).

MOOC
Only one study provided MOOC [32], videos for brief theoretical explanations, clinical cases, and discussion forums for analysis, and professional reasoning was provided to various OT subjects (e.g., support products, ergonomics, and autonomy). The MOOC group showed a high participation rate in learning and a significant difference in cognitive and affective empathy scores before and after the tests and showed higher academic performance compared to the control group that provided only the undergraduate program (Tables 1, 2).

Technologies used to promote active learning
To promote active learning in OT teaching and learning, technologies are largely used for thinking and reflection, discussion, peer learning, and online gamification learning, either synchronously or asynchronously. In thinking and reflection, real-time question and answer during online lectures and labs, multimedia content provision, reflection writing, assignments and feedback, one-minute paper, and student-generated video upload via educational platforms such as LMS were performed. Interactive communication through a platform, discussion boards of the LMS, applications such as flip grids and padlets, and blogging were used. In peer learning, think-pair-share, jigsaw technique activities, and game software were used in real-time, and group activities using online platforms such as Google Drive were conducted. In gamifying online learning, pop quizzes and game software were used (Fig. 3).

Discussion
This scoping review was conducted to examine digital learning design in OT education, integrated key clinical skills, outcomes, participant experiences, and technologies that promote active learning. The studies included in this review were quantitative, qualitative, and mixed studies to explore digital design in OT education, and most of the studies were observational, qualitative, and mixed studies of these two designs. Additional studies are needed to identify the effectiveness of digital design in OT education. Five major designs have been identified: blended learning, hybrid learning, flipped classroom, and distance learning (including e-learning and MOOC).

Key clinical skills integrated into digital learning
Professional reasoning is an essential feature of healthcare practice that focuses on assessing needs, planning interventions, and delivering and evaluating health care [47]. Unlike professional reasoning in other fields of health care that focuses on diagnosis or impairment, professional reasoning in OT considers the client, the environment, and the context of performance [39]. For occupational therapists to set treatment goals and outcomes that are appropriate for their clients, they must consider the knowledge, beliefs, environment, and context of their clients and their families [48]. Professional reasoning is the core competency of professional occupational therapists, which is paramount in the client's problem-solving process and is one of the competencies that must be fostered in the university curriculum. Clinical skills are an important feature of the healthcare professional's curriculum through specific curriculum hours, a wide range of assessment techniques and procedures, and specially designed laboratories [49]. Clinical skills included physical examination skills, practical procedures, communication skills, and management. Basic scientific knowledge, procedural knowledge, and professional reasoning components are the components for acquiring clinical skills. That is, basic scientific knowledge (declarative knowledge) and procedural knowledge are the underlying knowledge for professional reasoning [17]. Clinical skills in OT include trained basic scientific knowledge to understand the pathophysiology of the client's impairment, procedural knowledge that serves as a theoretical framework for understanding the client's problems and solutions, and planning OT intervention strategies. In acquiring these two clinical skills, professional reasoning skills, which is a practical problem-solving process based on case scenarios and related clinical situations, is achieved [50,51].
Most studies in this review addressed specific subjects and included procedural knowledge with the exception of studies that involved some or all semesters of OT courses. The subjects included procedural knowledge and/or professional reasoning components addressing various OT major courses (e.g., FOR, adaptive equipment, mental health) or interdisciplinary courses (e.g., interprofessional team skills), or case-based professional reasoning training (e.g., sensory processing, OPPM). This shows that professional reasoning, an important competency in OT education, and the procedural knowledge underlying professional reasoning can be integrated into digital learning. One study addressed basic scientific knowledge about human anatomy, and 3D anatomy software was integrated during F2F classes [25]. The 3D software can help understand anatomical relationships beyond the textbook-based 2D format used in the traditional OT curriculum. These results recognize that advanced technology is a useful tool for enhancing basic science knowledge and is becoming a major form of teaching and learning.

Digital learning designs and outcomes Blended learning
Blended learning involves F2F classes accompanied by online activities and materials. The online materials used were not intended to replace the F2F class session but to supplement the content discussed in the classroom [19]. The blended courses in this review showed similar or greater improvement in learning outcomes compared to the F2F group [25,26,31,39]. This is in line with the blended learning designs having a more effective or equivalent effect than the F2F class on the learning outcome in PT education, as reported by Ødegaard et al. [13]. In addition, students in the blended learning design studies reported subjective opinions such as improvement of communication between students, appropriate course design and online learning environment to achieve learning outcomes and improvements in autonomy and active participation [26-28, 31, 38]. This is consistent with the results of previous studies that framed learning goals; the use of technology to support the achievement of those goals in education improves Fig. 3 Technologies used to promote active learning student engagement, student-student communication, student-instructor communication, and promotes critical discussion [52,53]. Two studies reported the usefulness of a software tool (3D anatomy and game application for adaptive equipment) used during the F2F class [25,28]. Game-based learning is becoming an educational technique for reproducing some or all of the clinical experiences in healthcare professional education [54]. In addition, the use of technology such as 3D anatomy has the advantage of increasing students' motivation to learn and shortening their learning time [55]. Although there is still not enough clear evidence that software is a superior learning tool in OT learning and teaching, it can be a promising tool to enhance clinical skills in OT education.

Flipped classroom model
Two studies adopted the flipped learning model and reported a positive impact on learning outcomes in OT education [33,44]. Ødegaard et al. [13] reported a positive effect of flipped learning on learning outcomes in PT education through a meta-analysis, but Evans et al. [56]. reported that the effect was not clear in healthcare higher education. In OT education, sufficient studies are needed to verify the effectiveness of flipped learning design. The pre-class learning activities of the flipped learning model motivate students, promote participation in learning, and improve the self-regulation, flexibility, and transparency of the learning process. In-class activities help with higher-order thinking by providing opportunities to add new content to existing knowledge to solve problems [57]. These features of flipped design were reflected in the positive experiences of students reported in flipped design studies in this review. They reported positive experiences, such as peer interaction and cooperation, improved participation in learning, and increased individual learning time through the flipped learning design.

Hybrid learning
Two of the studies adopted a hybrid learning design. The hybrid and F2F groups showed similar effects on academic outcomes [42], preparation for certification exams, learned skills, and sense of belonging [43]. It was also reported that the number of hybrid course graduates for the state OT association was significantly higher than that for F2F [43]. This means that hybrid learning is a learning method with the potential to reach a wider audience by allowing access to education anywhere as well as equality of learning outcomes. In a review by Raes et al. [58], participants reported that hybrid learning is flexible in students' course attendance in higher education, and creates richer learning experiences through collaboration and connections between F2F and distant students, thus facilitating students' exposure to broader perspectives and ideas. This is consistent with the results of hybrid learning included in this review. However, there are challenges in the design and implementation of educational strategies and technical systems that are suitable for hybrid learning [58]. In addition, there is insufficient research to discuss the effectiveness of hybrid learning and students' experiences in OT education. In future OT education, more research is needed on various educational scenarios for hybrid learning and their effect on learning outcomes.

Distance learning; E-learning, MOOC
Distance learning is the most important phenomenon in higher education today [59], providing learners with flexibility, mobility, and choice for learning [60]. E-learning was the most common distance learning method identified in this review (n = 10), and one study adopted the MOOC [32].
Distance learning has become an increasingly important mode of learning and teaching in conventional universities, continuing education, and corporate training [61]. The features of distance learning, including these various learners, are discussed in this review. Distance learning studies included a variety of learners, including fieldwork education and continuing education for clinicians, as well as campus classes for OT students. Compared with traditional learning, distance learning in professional healthcare education has reported similar or small positive effects on professional knowledge, attitudes, skills, and satisfaction [62,63]. The results of distance learning in this review are also consistent with those of previous studies. Compared with F2F, the distance learning course showed similar or greater improvement in academic performance [29,30,32,37]. The pivotal role of e-learning is interaction and practice exercises, repetition, and feedback, which are related to improving learning outcomes [64]. This is consistent with the perceptions of students' experiences. The roles of e-learning were implemented with various web-based tools, including the virtual classroom platform, LMS, and experiences such as interaction and learning autonomy and promotion of higher-order thinking. However, some students commented on the pedagogical and technical challenges of e-learning. They reported that they preferred the combination of e-learning and F2F [29] and that e-learning has limitations in interaction between learners [37], unlike F2F. Technology is a physical tool, not a theoretical thinking tool or concept. However, it changes the way we think about tasks and how we perform them [65]. Therefore, in e-learning, it is necessary to plan an appropriate learning design for the teaching and learning platform in consideration of the characteristics of the subject (e.g., theory class/practical class). In addition, setting up an appropriate online environment for active learning, such as interactions between learners, and equipping instructors and learners with competence in using the technology will be important aspects.

Digital learning promotes active learning
Active learning strategies are applied to online sessions for various reasons. The purpose of active learning is to engage learners in higher-order thinking (e.g., analysis, synthesis, and evaluation) that enables them to assimilate, apply, and sustain learning [66]. It also accommodates learners' diverse learning styles, promotes learner achievement, strengthens motivation, and enables them to learn more [66]. Most of the studies in this review applied various active learning strategies, either synchronously or asynchronously, such as thinking and reflection, discussion, peer learning-group activity, and gamifying online learning through various contents delivered electronically. An online session involves the continuum of content delivered electronically, from single assignments [67], and the use of computer-based learning management systems to fully web-based courses [68]. In particular, nine studies in this review used management system platforms such as Blackboard, WebCT (web courset Tools), and Moodle [26, 27, 31, 34-36, 41, 45, 46], most of which have been applied in e-learning course design. The core functions of the system are student management and tracking, material presentation, communication, scheduling, and learner testing. These systems focus on collaboration between learners and instructor feedback through discussion forums and student e-projects. It is therefore well-suited for engaging learners in active learning strategies, which are active processes that allow instructors and learners to become knowledge-building partners [69]. Online sessions of blended, flipped, and hybrid learning also played a leading role in integrating active learning with effective learning activities, such as discussions, project-based or problem-based assignments, or laboratory exercises. Students who participated in these courses reported that active learning strategies could provide immediate and frequent feedback from instructors during active learning activities and facilitate collaboration and interaction with other students. In addition, students reported that it helped them to have a broader understanding of the learning content and build their own learning style. This implies that, in OT education, an online format can be an effective means of acquiring knowledge and skills by integrating active learning strategies. In addition, it is necessary to plan a learning design that considers the effective active learning strategies that can be incorporated into the online format.

Limitations
Due to the nature of the scoping review, which aims to provide an overview or map of the evidence, this study did not evaluate the risk of bias, so it was not possible to clarify the reporting, methodological quality, and intervention effectiveness of the included studies. Some studies showed a lack of detail in interventions, while others reported non-validated outcome measures such as selfreports and underreported statistical methods. It is difficult to evaluate the effectiveness of different designs in digital learning because of the limited number of studies in each digital learning design, and many of the studies included in this review involved qualitative analyses of students' perceptions of learning experiences. However, we found positive responses to the design of digital learning that included improved academic performance, professional reasoning, learning participation and satisfaction, active learning, self-confidence, and overall efficiency of learning. Although the formation of the research question and search process was systematically conducted for a high level of scientific quality, the search strategy and exclusion criteria may have resulted in the omission of related studies. In addition, although various types of digital learning designs were identified and analyzed in this review, the definitions used may not be complete, and thus, there may be limitations in comparing designs and synthesizing the results. Finally, although this analysis of this clinical skill type may be framed as outside this scoping review, this is not the main purpose or intent of this study. In the future, it will be necessary to demonstrate outcomes, including the effectiveness of digital learning, using more robust study designs and experimental studies. With the rapid evolution of the use of technology in learning and the expanding associated literature, it is imperative that the definition and division of digital learning are clarified.

Conclusions
This review identified the digital learning designs applied in OT teaching and learning. The digital learning designs identified in this review were flipped learning, blended learning, hybrid learning, and distance learning, including e-learning and MOOC. Among the components of clinical skills, professional reasoning is the core competency of professional occupational therapists, and procedural knowledge is the main knowledge to acquire. This review has shown that these components of clinical skills can be integrated into digital learning in OT education. Digital learning designs applied to OT education have many benefits. This includes improving the learning outcomes of knowledge and skill acquisition, enhancing learning participation and reflection, and collaboration between learners. In addition, various technologies used in digital learning facilitate active learning by providing learning strategies, such as thinking and reflection, discussion, peer learning-group activity, and gamifying online learning, either synchronously or asynchronously. Although digital learning designs have had a positive impact on OT education, the results are limited to the OT population included in this review. Therefore, it is necessary to confirm the results of future studies with larger experimental designs. In addition, some studies have reported minimal barriers to digital learning. This review suggests a need for digital learning design plans that consider learning subjects and appropriate technologies for effective learning.